The short answer
Tell the earlier story in the history, identifying what the patient, GP or paramedics reported or did. Reserve Examination for findings from the treating clinician’s current review. The ED treatment and plan should describe care given or planned in ED, rather than repeat what happened before arrival.
Start with a sourced timeline
An ED note may draw on several accounts: a GP’s concern, treatment at a nearby clinic, paramedic observations and the receiving doctor’s examination. Put each event in time order and name its source. “GP queried SVT and called paramedics” is part of that history, not the ED doctor’s diagnosis.
A patient’s recollection also needs attribution. “Patient reports receiving fluids” may not carry the same certainty as an ambulance medication record. Keep that distinction if it affects the clinical meaning.
Reserve Examination for current findings
Use Examination for the treating clinician’s observations, vital signs and physical findings. A heart rate measured before arrival may still matter, but label it as an earlier observation. Otherwise the reader could mistake it for a second measurement made in ED.
Completed ECGs and blood tests belong under investigations with results and status. A plan to obtain a result belongs under the plan until it is available.
Separate earlier treatment from the active plan
Document IV fluids given at an adjacent clinic in the history. Document ED treatment and response in the plan or treatment section. If no ED intervention was required, do not duplicate the pre-arrival intervention as though it occurred in ED.
Common questions
Can a GP result appear in the note?
Yes, with attribution and timing, where relevant to the current encounter.
Why does attribution matter?
It lets the reader distinguish what was reported, previously observed and currently confirmed.
Sources and product details
These guides describe DictaMed’s current workflow and general documentation principles. Follow your workplace policy and use clinical judgement for each patient.